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The Health Equity Lens


I Introduction
II Application of the HEIA Tool
III Supporting HEIA
IV Lessons Learned
V Conclusion [Edited March 7, 2014]
VI References
VII Resources

--submitted by Kashfia Alam, MPH Practicum Student, Health Nexus

I Introduction

Board the Metro train in Washington DC, and as you head up toward Montgomery County, Maryland from downtown DC, you might be surprised to learn that life expectancy increases about a year and half for each mile traveled. The average individual living in the higher-income suburbs near the Shady Grove station will live twenty years longer than the typical city dweller around Capitol Heights (Marmot, 2004). Closer to home in Hamilton, the average age at death is 67 years of age in a lower income neighbourhood and as high as 86 in a higher income neighbourhood (Public Health Ontario, 2013). These differences in life expectancy indicate that the root causes of poor health and illness goes beyond our own attitude and behaviour related to health, pointing instead towards the social and economic conditions in which we live. A huge body of research demonstrates that people with higher incomes, more education, and other indicators of socio-economic conditions have better health than those lower in the scale (Marmot, 2004). This brings us to the concept of equity versus equality, and although these terms are sometimes used interchangeably, there are important distinctions between them.  

Programs and policies based on principles of equity recognize that the underlying social and economic causes of poor health results in different needs in the population. Equity ensures that people have what they need to enjoy full, healthy lives. In contrast, promoting equality means treating everyone the same way, without acknowledging that people have different needs. The SGBA (sex and gender-based analysis) e-Learning Resource Centre (2013) provides an excellent example to illustrate the difference between equity and equality. Consider runners sprinting around an oval track during a competition. If we are interested only in equality, we would make sure that all runners start at the same place on the track. However, we know that runners in the inside lanes have a distinct advantage over runners in the outside lanes because the distance they have to travel is shorter. In promoting equity, we would have the runners start in different places, in order to offset the disadvantages facing those in the outer lanes. Both equality and equity aim to promote fairness and justice, however, equity takes into consideration that factors such as language, education, poverty, gender, can act as barriers that place certain population groups at a greater disadvantage over others.    

According to Whitehead (1992), health inequities are differences in the health outcomes of specific populations that are “systematic, patterned, unfair, unjust and actionable, as opposed to random or caused by those who become ill.” The first step towards achieving health equity is to understand the real extent of the problem. This includes identifying how a program or policy initiative can or will impact vulnerable or marginalized groups. The Centre for Addiction Research of BC (2013) has identified a variety of tools and frameworks that have been developed with the purpose of understanding health equity impacts of programs and policies. Equity assessment tools have been adopted in different jurisdictions, including Australia, New Zealand, and United Kingdom, and are also endorsed by the World Health Organization. In Ontario, the Health Equity Impact Assessment (HEIA) tool was developed in collaboration between the Ministry of Health and Long Term Care (MOHLTC), Public Health Ontario, and Local Health Integration Networks. Based on international evidence in consultation with health service providers, the HEIA tool aims to reduce health disparities across vulnerable and marginalized population groups by identifying and mitigating potential unintended health impacts on specific population groups.

II Application of the HEIA Tool

In Ontario, a number of organizations have begun to utilize the HEIA tool to analyze the impact of their programs and policies. Examples include:

  • The Wellesley Institute has used the HEIA tool to analyze the negative health impacts on vulnerable populations for three Budget decisions: reducing child care funding and subsidies, the elimination of the Hardship Fund, and limiting the development of affordable housing (Barnes, 2011). This example demonstrates how the HEIA tool can be utilized as an advocacy strategy to inform the policy development process.
  • Perth District Health Unit has applied the health equity lens to assess Nurse Chat, a program to provide accessible child and family health information and services to expectant parents and families. They are currently in the process of monitoring the impact of their mitigation strategies on the identified vulnerable and marginalized groups.
  • Health Nexus is currently using the HEIA tool to assess how the communications strategies for the 3M Health Leadership Award can be modified to encourage greater nomination and representation from specific population groups.

In Ontario, the application of the HEIA tool is still in its infancy, however, the growing trend indicates that service providers and decision makers are beginning to consider incorporating equity assessments into their planning, development and evaluation work.   

III Supporting HEIA

Ontario’s Ministry of Health and Long Term Care has invited Health Nexus to be a “champion organization” to support implementation of the HEIA tool. As a long time proponent of health equity, Health Nexus is pleased to be involved in these efforts. Health Nexus is providing a variety of capacity building supports and resources to organizations and individual practitioner, including training workshops, consultation and coaching support.

Several provincial organizations, including the Centre for Addiction and Mental Health (CAMH), the Wellesley Institute, the Canadian Mental Health Association (CMHA) and Public Health Ontario (PHO) are also providing support for the HEIA tool across the province. This group of organizations is supporting an HEIA Community of Interest, led by CAMH, which provides opportunities for practitioners to share experiences and generate evidence as well as resources, webinars, and expert knowledge on the HEIA.

The HEIA is an important tool in providing guidance to practitioners and decision makers on how to apply the health equity lens to improve their specific program or policy. Health Nexus has begun to collect examples from individuals, networks and organizations that have used the HEIA tool. These case studies will highlight the processes used to conduct the HEIA and identify the results of the assessment. If you have conducted an HEIA on a program, policy or initiative, and you are interested in sharing your story, please contact Health Nexus at (416) 408-2249 or [email protected].

IV Lessons Learned

Through work in supporting organizations to conduct HEIAs and in the case studies have collected, we have identified several key learnings:

As highlighted above, there are important distinctions between “equity” and “equality,” however, new programs, policies, and initiatives continue to be implemented based on principles of equality. One of the lessons learned is the need to build a shared understanding of “equity” and how it is different from “equality.” Before conducting the HEIA, it may be necessary to discuss and define health equity, and the purpose of applying the health equity lens to analyze the impact of programs or policies. This discussion becomes even more important when we are using the HEIA tool to assess a non-health related program or policy initiative. A shared understanding of health equity and its importance will also motivate those involved in carrying out the assessment to commit towards utilizing the tool properly.

Sufficient support from program managers or directors to conduct the HEIA, and implement recommendations from the assessment, is critical. A staff or team member may be committed to using the HEIA tool, however, if there is resistance from managers or directors in using the tool, it may be more difficult to conduct the assessment. Institutional support becomes even more important when mitigation strategies to modify the current program or policy are considered based on the findings from the HEIA tool.

In addition, engaging the population groups that have been identified in the HEIA to discuss the determinants, potential impacts, and mitigation strategies will further enhance the lessons learned from application of this tool. For example, Health Nexus is currently utilizing the HEIA tool to assess the equity impacts of the 3M Health Leadership Award by consulting with internal 3M team members, as well as conducting interviews with key informants from the identified population groups. Although the literature can be a valuable source of information, conducting focus groups and interviews with staff members and population groups will result in more enriched data for the HEIA, while encouraging greater participation from diverse groups in the completion of the health equity impact assessment.

V Conclusion

Dr. William Foege, a former director of the U.S. Centers for Disease Control and Prevention summed up health in the 21st. century in four words, “spectacular progress, spectacular inequities.”  We know through research and our experience of trying to work upstream that health equity is possible through direct action on the determinants of health. While there are persistent and widening gaps in equity, there is also potential for change as more and more practitioners and organizations incorporate equity assessments such as the HEIA tool into policy, program planning and evaluation.

VI References

Barnes, S. (2011). The Real Cost of City Cuts: A Health Equity Impact Assessment. Wellesley Institute. Retrieved from:

Centre for Addiction Research of BC. (2013). Equity Lens in Public Health: Health Equity Tools. University of Victoria, Victoria BC.  Retrieved from:

Marmot, M. (2004).The Status Syndrome. New York, NY: Henry Holt

Public Health Ontario. (2013). Planning Through An Equity Lens. Retrieved from:

Sex- and gender-based analysis(SGBA). (2013). Distinguish between Equity and Equality. Retrieved from:

Whitehead, M. (1992).The concepts and principles of equity and health. International Journal of Health Services.  22(3) 429-445.

VII Resources

Ministry of Health and Long-term Care
HEIA Workbook and Template:
The Wellesley Institute
Health Equity Impact Assessment resources:

Public Health Ontario
HEIA Public Health Unit Supplement
is a supplemental resource guide for public health unit staff to support their use of the HEIA tool in meeting the health equity requirements in the Ontario Public Health Standards and the Ontario Public Health Organizational Standards:

HEIA Online Course:

HEIA Community of Interest

National Collaborating Centre for Methods and Tools
How to conduct an HEIA:

Health Nexus
Health equity topics and tools:

SGBA e-Learning Resource
Rising to the Challenge: